Share of Urban and Semi-Urban

146

SPECIAL . no

Winning the COVID-19 Battle in Rural India: A Blueprint for Action Malancha Chakrabarty and Shoba Suri

JUNE 2021

© 2021 Observer Research Foundation. All rights reserved. No part of this publication may be reproduced, copied, archived, retained or transmitted through print, speech or electronic media without prior written approval from ORF. Introduction

s India welcomed 2021, the country was reporting less than 15,000 new COVID-19 cases per day between mid-January and mid-February. Soon, however, there was a surge, 1). A report by the State Bank of India (SBI) noted and on 7th April, the number of daily infections that by mid-May, the rural districts accounted for A 2 reached 126,260 with the seven-day daily average 50 percent of all new cases in the country. The crossing 100,000.1 By then it was clear, that the rural areas of Amravati in Maharashtra are worst second wave of COVID-19 in India would be far affected with a large number of new cases,3 and more severe than the first one. The steep rise in those of Nagpur in the same state have also become infections and deaths made headlines across the hotspots. About 35 percent of all COVID-19 world, as images of mass pyres and people queueing deaths in Haryana have been reported from the for free oxygen cylinders in temple grounds made rural districts, with the heaviest toll in Hisar (258), the rounds of social media. followed by Bhiwani (217), Fatehabad (159), and Karnal (150).4 The second wave has also hit the Today, two months later, while the number rural areas of Gujarat.5 The state reported 90 of active cases has come down in big cities, the deaths in 20 days from one village alone, Chogath, pandemic is fast spreading across rural districts, which has a population of 13,000. Two of India’s with the biggest increases being recorded in the largest and most populous states – Uttar Pradesh states of Rajasthan, Maharashtra, Uttar Pradesh, and Bihar—have also witnessed a steep rise in Karnataka, Andhra Pradesh, and Kerala (See Figure COVID-19 cases in their rural districts.a

Attribution: Malancha Chakrabarty and Shoba Suri, “Winning the COVID-19 Battle in Rural India: A Blueprint for Action,” ORF Special Report No. 146, June 2021, Observer Research Foundation.

a It was in these areas where photographs emerged of corpses floating in the river Ganga, and mass burial sites along the riverbed.

2 To be sure, the actual numbers of COVID-19 cases in the rural regions of India could be much higher than the official figures because of low testing rates6 rural India, managing the spread of the pandemic and people’s reluctance to get tested,7 to begin with. would prove to be even more difficult than what Given the severe shortage of medical facilities in the urban cities experienced earlier this year.

Figure 1: COVID-19 case trends in urban and rural areas

35,000

30,000 Rural Urban s 25,000

20,000

No. of Case 15,000

10,000

5,000

- n r d r Bhia Haryana Odisha Rajastha Jharkhan MaharashtraUar Pradesh Chhasgarh Andhra Pradesh Madhya Pradesh Himachal Pradesh Jammu and KashmiArunachal Pradesh State

Source: Times of India8

3 Figure 2 shows that by the peak of the first wave around September 2020, rural areas accounted for one in every three (33 percent) of all new cases. It districts, which is almost double the 34-percent was about 65 percent in both rural and semi-rural share of urban and semi-urban.

Figure 2: Covid-19 cases in Urban, Semi-Urban, Rural and Semi-Rural Areas

60 Urban Semi-Urban Semi-Rural Rural

) 40

10 Share in total new cases (%

April 2020 May 2020 June 2020 July 2020 April 2021 May 2021 August 2020 March 2021 October 2020 January 2021February 2021 September 2020 November 2020December 2020 Month

Source: The Hindu9

4 Figure 3: Vaccine doses administered per 100 persons in Urban, Semi-Urban, Rural and Semi-Rural Areas (2021) 35

s Urban Semi-Urban 25

Semi-Rural Rural 20

10 No. of doses per 100 person

January February March April May

Month

Source: The Hindu10

At the same time, the vaccination drive has been slow in the rural areas as compared to urban (See Figure 3). The key reasons for this include lack availability of doses, which has compounded the of internet connectivity, low smartphone access, lag.12 A December 2020 household survey across digital illiteracy, and apprehensions about vaccine 60 districts in 16 states found low preference for safety.11 Moreover, there is also a problem of vaccines, with only 44 percent willing to pay for it.13

5 Given that 65.5 percent of India’s entire population is rural,14 adequate steps need to be undertaken at the earliest to prevent the occurrence of a health catastrophe in rural India. An economic crisis is making the challenges more acute. As This special report describes the specific a response to the rise in infections, many states challenges wrought by COVID-19 in India’s such as Madhya Pradesh and Uttar Pradesh are rural areas, and outlines a ten-point agenda for under lockdowns to curb the spread of the virus. effective pandemic management and the revival Consequently, villagers who are mostly daily-wage of the rural economy. The rest of the report workers or street vendors in nearby towns have lost provides an overview of the government’s efforts their livelihoods. While remittances from family to manage COVID-19 in rural areas; discusses the members working in big cities were relied upon to specific challenges in those regions; and presents boost the incomes of the rural households, the rise in a ten-point strategy for immediate action. Among cases in the urban areas beginning in early February others, the report recommends the constitution led to another exodus of migrant workers from of a task force, and the provision of a special those cities, similar to what occurred in 2020 during economic package for the rural regions. the first wave and nationwide lockdown. Rural households suffered losses in household incomes as a result, pushing many to deeper indebtedness and worse hunger.

Media reports suggest that people in rural India are eating less and often not able to afford nutritious food like pulses and vegetables.15 Overall, a survey in More than 65% of India’s October 2020 among urban and rural communities entire population is rural; in 11 states found that almost 70 percent of households are not consuming nutritious meals, adequate steps need to be with about half of them skipping at least one meal undertaken at the earliest every day.16 If India is to prevent a humanitarian disaster in its hinterland, there is a need for an to prevent the occurrence effective strategy to control the spread of the virus, of a health catastrophe in as well as sincere and targeted efforts to reboot the rural economy and provide welfare services to the rural India. people.

6 Current Government Strategy

he central government in May 2021 released the Standard Operating Practices (SOP) on COVID-19 management in peri-urban, rural, and tribal areas.17,18 The blueprint 4. State health administrators to triage patients Ttasked the state health secretaries to oversee the in order to reduce mortality. implementation of the SOPs at the grassroots level. The following are the key actions listed in the 5. Vaccination to be stepped up, especially for strategy: those above 45 years of age. ASHA workers and block medical officers to mobilise the 1. Accredited Social Health Activistb (ASHA) workers population. to be trained by Panchayati Raj institutions to identify early signs of COVID-19. 6. Central and state government schemes to be leveraged for providing food rations, drinking 2. Women’s self-help groups to be utilised for water, sanitation, and employment under the promoting awareness on symptoms and COVID- Mahatma Gandhi National Rural Employment 19-appropriate behaviour. Guarantee Act (MGNREGA). Interlinkages with medical facilities in nearby districts/ 3. Test, Triage and Treat. The mechanisms for sub-districts to be established for emergency screening, isolation and referral of cases must services.19 be strengthened, along with the monitoring of home isolation cases. Facilities for COVID-19 care are to be ramped up, and focus to be given on mental health.

b ASHAs are community health workers instituted by the Ministry of Health and Family Welfare in the community to create awareness on health and its social determinants and mobilise the community towards local health planning and increased utilisation and accountability of the existing health services.

7 Community health workers are key in the government’s current COVID-19 strategy in the rural regions.

7. A three-tier structure to be set up: A Covid- care centre for mild cases; primary health centres or community health centres or sub- district hospitals for moderate cases; and district 8. The use of drones to be explored for delivering hospitals or private hospitals for severe cases. vaccines in remote villages and isolated Ambulances to be made available for the rapid communities.21 transport of patients.20

8 The COVID-19 Challenges in India’s Villages

a. Health infrastructure

India’s rural health infrastructure has improved since the implementation of the National Rural Health Mission and the Ayushman Bharat equipped to tackle the challenges posed by the Programme in 2018. However, it remains ill- COVID-19 pandemic. Rural India has historically had less access to health services. (See Figure 4.)

Figure 4: Basic Health Infrastructure in Rural India

200000 191461

180000 Required Funconing

160000 155404

140000

120000

100000

No. of facilies 80000

60000

40000 31337 24918 20000 7820 5183 0 Sub Centres Primary Health Centres Community Health Centres

Category of health facilies

Source: Ministry of Health and Family Welfare22

9 Health facilities in the rural districts are overwhelmed, even without a pandemic. According to Rural Health Statistics 2019-20, the average population covered by a Sub-Centre health facility in the rural areas is 5,729, as against the norm of 5,000; Figure 5: for Primary Health Centres (PHC), it is 35,730, while the norm is 30,000; and for Community Average Rural Health Centres (CHC), it is 171,779 against the norm of 120,000.23 There are considerable Population covered per differences among the states. (See Figures 5, 6, and 7) Both the PHCs and the Sub-Centres are Sub Centre in 2020 already overwhelmed in several states such as Uttar Pradesh, Bihar, Jharkhand, Madhya Pradesh, and Jammu Kashmir Ladakh Chandigarh Himachal Pradesh Maharashtra; the steep rise in COVID-19 cases is Delhi Punjab compounding the burden. Haryana Uttarakhand Meghalaya Arunachal Pradesh Sikkim

Uttar Pradesh Rajasthan Assam Bihar Nagaland Manipur Gujarat Jharkhand West Bengal Mizoram Madhya Pradesh Chhattisgarh Tripura Odisha D & N Haveli and Maharashtra Daman & Diu Telangana

Goa Andhra Pradesh

Karnataka

Puducherry Andaman & Nicobar Islands Lakshadweep Tamil Nadu Kerala

Rural Population Covered perSub Centres

7000&above 5000-7000 3000-5000 0 - 3000

Source: Ministry of Health and Family Welfare 24

10 Figure 6: Figure 7: Average Rural Average Rural Population covered per Population covered per Primary Health Community Health Centre in 2020 Centre in 2020

Jammu Kashmir Ladakh Jammu Kashmir Ladakh

Chandigarh Chandigarh Himachal Pradesh Himachal Pradesh Delhi Delhi Punjab Punjab Haryana Arunachal Pradesh Haryana Uttarakhand Uttarakhand Meghalaya Sikkim Arunachal Pradesh Meghalaya Sikkim Rajasthan Uttar Pradesh Assam Uttar Pradesh Rajasthan Assam Nagaland Bihar Bihar Manipur Nagaland Jharkhand Manipur Gujarat Mizoram Gujarat Jharkhand West Bengal West Bengal Madhya Pradesh Madhya Pradesh Mizoram Chhattisgarh Tripura Chhattisgarh Tripura Odisha D & N Haveli and Odisha D & N Haveli and Daman & Diu Maharashtra Maharashtra Daman & Diu Telangana Telangana Goa Andhra Pradesh Goa Karnataka Andhra Pradesh Karnataka

Puducherry Lakshadweep Tamil Nadu Andaman & Nicobar Islands Puducherry Kerala Lakshadweep Tamil Nadu Andaman & Nicobar Islands Kerala

Rural Population Covered perPrimary Health Centres 50000 &above Rural Population Covered perCommunity Health Centres 40000 - 50000 500000 & above 30000 - 40000 200000 - 500000 20000 - 30000 100000 - 200000 10000 - 20000 0 - 100000 0 - 10000

Source: Ministry of Health and Family Welfare 25 Source: Ministry of Health and Family Welfare 26

11 The Sub-Centres, Primary Health Centres, and Community Health Centres in rural India often lack diagnostic equipment and medicines.27 Media reports on Bihar, for example, have noted the absence of ambulances in the health centres, forcing b. Human resources many patients to walk long distances to access test kits and basic medicines like paracetamol.28 India’s rural districts suffer from shortages in qualified medical personnel. The system rests Technology can bring improvements to the on the ASHAs, who act both as providers and current healthcare system, especially in the rural facilitators of medical care. India’s 1.3-million- areas. Enduring challenges remain, however, strong army of female health activists (Anganwadi such as lack of connectivity and infrastructure, Workersc) have played a crucial role in managing and of smartphones. Although developing robust the COVID-19 pandemic, conducting contact- IT systems has been one of the objectives of the tracing and engaging in sensitisation campaigns Ayushman Bharat Programme, not all ASHAs among the population. However, according to a have access to smartphones nor are all Sub- survey by Oxfam,29 over a quarter of the ASHAs Centres equipped with computers. Overall, rural have not received either protective gear (masks populations still rely on basic mobile phones, and gloves) or their monthly stipends. being without means to purchase smartphones. Therefore, central government efforts, such as There is a critical shortage of medical doctors, the Health Ministry’s guidelines regarding tele- paramedical staff, and health workers/Auxiliary consultation with specialist doctors—will likely fail Nurse Midwives in large parts of the country. in rural India. According to Rural Health Statistics 2019-2020, 14.1 percent of the sanctioned posts of Health Workers (Female)/ Auxiliary Nurse Midwivesd

c Anganwadi workers are community-based frontline workers of the Integrated Child Development Scheme program of the Ministry of Women & Child Development. d ANM is a village-level female health worker.

12 and 37 percent of the sanctioned posts of Health Workers (Male) are currently vacant in the Sub- Centres. Further, there is a shortage of doctors female health workers (5,066), pharmacists (1,704 positions) in primary health centres across (6,240), and laboratory technicians (12,098) (see the rural areas, as well as nursing staff (5,772), Figure 8).

Figure 8: Human Resources in Rural Primary Health Centres

30000

24918 24918 24918 24918 24918 25000

l 20000

15000 12098

No. of personne 10000

5772 6240 5066 5000 1704

0 Doctors Nursing Staﬀ Female Health Pharmacists Laboratory Workers/ANM Technicians Category of health personnel

Required Shorall

Source: Ministry of Health and Family Welfare30

13 A similar situation prevails in the CHCs which are designed to provide specialised medical care including surgeries. They are operational with Rajasthan, Karnataka, and Uttar Pradesh face about 24 percent of required specialist doctors some of the most severe shortages of doctors, (See Figure 9). States like Odisha, Chattisgarh, medical officers, and nursing staff.

Figure 9: Human Resources in Rural Community Health Centres

40000 36281

35000 l Required Shorall 30000

25000 20732 20000 15775 15000 No. of health personne 10366 10000 5183 5183 5183 5000 2884 3334 355 249 284 0 Doctor Medical Oﬃcers Radiographers Pharmacists Laboratory Nursing Staﬀ Specialists Technicians Category of personnel

Source: Ministry of Health and Family Welfare31

14 The District Hospitals are experiencing the same problems. As Table 1 shows, the number of doctors and paramedical staff has increased only marginally since the launch of the Ayushman c. Public investment in healthcare Bharat programme a few years ago. Since the initial onslaught of the pandemic, there has been The last decade saw some degree of public a drastic reduction in the number of doctors at investments in the country’s tertiary healthcare district hospitals (from 24,676 to 22,827) as well as sector, in particular, in the supply of health paramedical staff (from 85,194 to 80,920). workforce: between 2014 and 2019, there has been a 47-percent increase in the number of government medical colleges, compared to a Table 1: 33-percent increase in private medical colleges. The number of undergraduate medical seats Number of doctors and has seen a jump of 48 percent, from 54,348 in the academic year 2014-15 to 80,312 in 2019- paramedical staff in 20. While India was expanding the number of seats in government medical colleges, it was district hospitals in India also leveraging the private sector to fill gaps in personnel and healthcare delivery. However, these tertiary hospitals are almost exclusively 2018 2019 2020 located in the urban areas. Doctors 24 899 24 676 22 827 Paramedical 77 203 85 194 80 920 The imperative is for financial resources to be Staff pumped into the system through investments in 32 Source: Ministry of Health and Family Welfare the National Rural Health Mission (NRHM), so that staff shortages are addressed. Unfortunately, no such improvement is being seen in the funding towards the National Health Mission (NHM), which houses NRHM, despite the government’s own National Health Policy 2017 declaring that government expenditure in health will reach 2.5 percent of GDP by 2025. Indeed, analysts note a widening gap between required and actual central funding.33 (See Figure 10)

15 Figure 10: India’s Path to 2.5% of GDP on health

Source: Kurian (2020)33

Infrastructure creation and upgrade in rural areas also stagnated in the very same states with the most acute needs. For example, analysis has shown that that the pace of upgrade of health facilities Focus Statese—i.e., Bihar, Rajasthan, Chhattisgarh, into Health and Wellness Centres (HWCs) under Madhya Pradesh, Odisha, Jharkhand, Uttar Ayushman Bharat has been slower than planned, and Pradesh, and Uttarakhand, who together account a high number of functional HWCs are concentrated for around half of India’s population—have in the states with relatively better resources. High- disproportionately low numbers of HWCs.34

e Due to unacceptably high fertility and mortality indicators, the eight Empowered Action Group (EAG) states (Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Odisha, Rajasthan, Uttarakhand, Uttar Pradesh and Assam), which account for about 48 percent of India’s population, are designated as “High Focus States” by the Government of India.

16 The 2021 budget did not veer from the same trajectory, despite some stop-gap funding necessitated by the pandemic. Between the estimates of Budget 2020 and those of Budget 2021, there Understandably, India languishes at the bottom was a paltry increase of 10.5 percent, when the of the BRICS countriesf in terms of government requirements on the ground are far higher. The investments in healthcare (See Figure 11). The amount allocated in 2021 — INR 746,020 million country is indeed the poorest in the grouping as — was in fact 10-percent lower than the revised measured in per-capita incomes. estimates from the previous year, which was INR 824,450 million.35

Figure 11: Domestic general government expenditure (% of GDP) in BRICS countries 5

4.5 P 4

3.5

2.5

1.5 Health spending as % of GD 1

0.5

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 BRICS Country Brazil Russian Federaon India China South Africa

Source: World Bank36

f The emerging economies of Brazil, Russia, India, China, and South Africa.

17 Nonetheless, there was a notable lack of any considerable improvement over the past two decades—a period of relatively high economic capita incomes (see Figure 12). Even smaller growth for the country. India’s general government neighbouring countries like Nepal, or African expenditure on health as a percentage of GDP countries that receive development assistance is lower than many countries with lower per from India, spend more resources on public health. Figure 12: Countries with lower per capita incomes than India but higher spending on health as a percentage of GDP

16 Tuvalu

14 P

10 Kiriba

8 Marshall Islands

6 Lesotho Health spending as % of GD Nicaragua Solomon Islands Micronesia, Fed. Sts. 4 Kyrgyz Republic Samoa Malawi Timor-Leste Tonga Niger Rwanda Burkina Faso Kenya Burundi Tajikistan Honduras Madagascar Vanuatu Papua New Guinea Mauritania 2 Uganda Zambia Mozambique Nepal Cambodia Ghana Liberia Tanzania Djibou Togo India Sierra Leone Mali Zimbabwe Sudan Pakistan Cote d'Ivoire - - 1,000 2,000 3,000 4,000 5,000 6,000 7,000

Per capita incomes

Source: World Bank37

18 d. Data collection and dissemination

Efficient data collection and data-sharing are critical components of any effective COVID-19 management strategy, whether for urban or rural Registrar General of India to obtain more accurate regions. Health experts have often asserted that death statistics in rural areas—this would involve data should inform and drive India’s COVID-19 getting municipalities to release daily or weekly management strategies and patient care, rather death figures, and mapping hotspots. The sample than guidelines developed in other countries registration system involves sending teams to because the conditions in the country are different. a random sample of villages across the country Similarly, the template for the rural areas should to ask every family if there has been a birth or a not be a replica of that for urban regions, because death in the past certain number of months. If their conditions may be unique to those populations anyone has died in the family, then they are asked and geographies. to fill in a form to give details. Data derived from the registration can serve as proxy for the actual Given the severe shortage in testing capabilities number of deaths in the region, and how many of and poor data collection, an accurate picture of the them were Covid-related. spread of COVID-19 in rural areas remains absent. Deaths are also being undercounted in villages. e. Food insecurity and Economic crisis Most deaths are not registered in rural India and it is easier to bury the dead in fields and open areas.38 As discussed briefly earlier, significant proportions Without reliable data, policies to curb the spread of of the country’s village populations have lost the virus and treatment of afflicted persons will be their livelihoods due to the pandemic; many have even more challenging. been pushed to worse states of indebtedness. Economist Pronab Sen predicts that unlike in According to noted epidemiologist and Director 2020, when rural India was the “bright spot” in of the Centre for Global Health Research, Prabhat the national economy, these regions are going to Jha, better death data is crucial in effective be badly affected in 2021.40 If farmers are not able management of the pandemic because it helps to access the markets due to either fear of getting in identifying the hotspots.39 He recommends infected, or a lockdown, then rural incomes would conducting a Sample Registration System by the fall significantly even with a productive harvest.

19 Moreover, non-agriculture services account for about 60 percent of rural incomes, and a fierce spread of the virus—and, as a potential response, lockdowns—will adversely affect the service sector. this is meant to reach 800 million people up to India saw this in 2020, when the lockdowns that November 2021.42 These efforts, however, might were implemented to arrest the initial onslaught of just prove inadequate given the current hardships the pandemic threw the economy into turmoil. that rural India is going through, and the long- term economic fallout of the pandemic. Families who have no source of income, food or medicines can hardly be expected to strictly If the past one and a half years of the pandemic follow COVID-19 norms like social distancing, has taught anything, it is that lockdowns not only handwashing, and wearing masks. The state has to create panic, but also bring disproportionate step in to take care of the needs of its citizens when difficulties for the poor. These restrictions on they lose their livelihoods due to lockdowns and movement and closure of non-essential services, are compelled by restrictions to stay at home. As must be accompanied by schemes such as rations things are, nutritional services have been disrupted or the setting up of community kitchens. across the country. The 2020-21 Union Budget saw an enhanced allocation of INR 356,000 million f. Disproportionate impacts on women for nutrition-related programs and INR 286,000 million allocated for women-related programmes. Even without a health crisis such as the The government has also announced a relief COVID-19 pandemic, rural women in India package of INR 1,740 billion under the Pradhan face cascading challenges: lack of education Mantri Garib Kalyan Yojana for the poorest of the and employment, more hours spent on unpaid poor.41 This included the provision of an extra five domestic work, higher risk of maternal mortality, kilograms of wheat or rice and one kilogram of and domestic violence. Women account for more pulses every month. than 70 percent of agricultural labour force in the country, where there is little pay and social Several other measures like the ‘One Nation, protection, if at all.43 A mere 27 percent of women One Ration Card’ scheme to avail food grains have completed 10 or more years of schooling in under the National Food Security Act could rural areas as compared to 51 percent in urban.44 benefit migrant workers. The Indian government Indeed, even as women play an important role has announced five kilograms of food grains for in the rural economy—being farmers, wage individuals listed under the National Food Security earners, and entrepreneurs—they continue to Act, 2013, through the public distribution system; face gender-based discrimination.45

20 Teenage pregnancies, for example, are almost double for rural women (9.2 percent) compared to the incidence among their urban counterparts (5 percent) as per the NFHS 4 (2015-16). These The pandemic has only worsened the situation: pregnancies occur due to various reasons like media reports suggest that many pregnant women poverty, lack of education, and employment in rural India are opting out of institutional opportunities. It contributes to the rise in maternal delivery because of fear of having to undergo a and child mortality, and intergenerational COVID-19 test.50 In the absence of a gendered undernutrition.46,47 As the pandemic spreads across response to the pandemic, current inequalities the rural areas, the women—already reeling from faced by rural women will only get exacerbated. the consequences of gender-based biases—are bearing a greater burden of the economic fallout. g. Migrant Labour Families find less food to eat, and the women— assigned by societal norms to partake of less in the Rural-urban migration in India has a ‘circular household’s meagre resources—suffer even more. character’: migrants do not settle permanently Before COVID-19, data from 2015-16 has shown in cities but continue to maintain close links with the worsening incidence of anaemia in India’s their villages.51 In India, large numbers of people women; the prevalence among rural women (15-49 who leave the villages in search of livelihoods do years old) is more than 50 percent. not find jobs in the formal sector. In the words of noted scholar, Jan Breman, “The people pushed Another area of concern in the rural regions is out of agriculture do not give up the habitat maternal healthcare. Unlike during the first wave of which keeps them embedded in the village of the pandemic, when COVID-19 was mostly “mild” their origin; first and foremost, because they in pregnant women, in the second wave, experts may have been accepted in the urban spaces as are seeing many pregnant women succumbing to temporary workers but not as residents. It means COVID-19 complications. Pregnant women with of course that they simply cannot afford to vacate weaker immune systems developed widespread the shelter left behind in the hinterland. This is scarring after getting infected by the virus.48 In in addition to the fact that dependent member of the rural districts, even as maternal mortality has the household do not join them on departure.”52 declined in the past decade, it remains high at 143 Circular migrants, a term Breman uses, are per 100,000 livebirths.49 poorly paid, have long working hours, lack legal protection and social security benefits, and do not have proper basic shelter. They are forced to return to their villages after periods of casual employment.

21 During the nationwide lockdown in 2020, many of these migrants failed to find the informal jobs that sustained them in cities and had little choice but to undertake the arduous journey back to their ill-equipped for following the norms related village. A similar exodus, of a smaller magnitude, to home quarantine. Many households do not was observed in February-March 2021. The threat have a second toilet for COVID-19 patients; they is that as the virus mutates further, migrants could typically have one or two rooms which are used be carriers of deadlier variants in both rural and to store grain, while the family members sleep urban areas. Migrants must therefore be identified together in one room or angan. This is a theme as a high-risk group that needs targeted care. carefully explained on Twitter by Bhairavi Jani,55 an entrepreneur who lives in the Himalayan town h. Societal attitudes of Pithoragarh in the state of Uttarakhand. Jani underlines the measures of how ill-equipped Absent systematic research so far, there is anecdotal the rural healthcare system is and why certain evidence of villagers refusing to be tested and COVID-19 protocols will fail in a village setup. In turning away health workers. For instance, Pradep a series of tweets that have resonated with many Kumar, a doctor in a Primary Health Centre in on the platform, she calls for creating awareness Katihar, Bihar laments,53 “We send mobile testing in the villages to overcome false beliefs, creating teams in villages but they are not interested. Due isolation centres at panchayat ghar to be managed to the stigma attached to Covid, most of them by ASHAs, and ramping up testing. hide their symptoms and avoid testing.” Indeed, there is extreme fear and stigma associated with Villagers are also falling prey to unqualified COVID-19—and it might not be peculiar to the medical professionals and unverified information rural populations. The excesses witnessed during circulating in social media.56 News reports found the national lockdown have also contributed to their people, for example, in rural Madhya Pradesh fears.54 Some people are also hiding symptoms out and Haryana who have had no choice but to of fear of being shifted to isolation wards. At the approach unqualified medical practitioners: they same time, home isolation—recommended by the do not have adequate information with which to Health Ministry for mild cases of the disease—is make decisions, they fear being sent to isolation extremely difficult. Family size is commonly larger wards, there is shortage of medical facilities, and in rural areas and three generations living together city hospitals are overcrowded.57 The lack of is more of the norm. Moreover, rural homes are information relates to vaccination as well—and it is not uncommon to hear of rural villagers resisting government vaccination drives.58

22 Recommendations for a Ten-Point Agenda

1. Constitute a task force. The government of India should immediately form a task force with members from the ministries of Health, Rural Development, Agriculture, and Panchayati 2. Raise awareness. Raising awareness through Raj, the state governments, along with experts a massive public outreach campaign should in health and other areas like sociologists and be among India’s first steps in its fight against economists. This task force should have two COVID-19 in the rural districts. India has components: enforcing COVID-19 protocols conducted successful public information and improving rural health infrastructure. The campaigns for health issues like polio, HIV/ group which focuses on protocols will raise AIDS, and leprosy. A similar large-scale awareness, disseminate correct information, campaign needs to be launched across the identify specific problem areas, and outline country, using all mediums of communication— solutions at the local level. Given the massive television, radio, newspapers, and door-to- diversity of rural India, a top-down approach door campaigns by health workers. This is is likely to be ineffective. The task force should especially important given the urban bias of regularly interact with local authorities to information currently being put out by the understand their specific challenges. For its part, government through television and radio. the group which will focus on strengthening The outreach programme should be based on the rural health infrastructure should outline a rural or tribal lifestyles, have rural characters, comprehensive strategy for effective distribution and be presented in vernacular languages. For of medicines, testing kits, mobile medical units, example, it would help rural households to and medical oxygen, set up makeshift hospitals learn how they can maintain social distancing for emerging hotspots, and prepare SOPs for within their own settings; they would also need COVID-19 patients keeping in mind the existing proper and adequate information on testing medical facilities in the region. and vaccination. Civil Society Organisations, NGOs, and local organisations should be roped in as partners in this exercise.

23 3. Strengthen the rural health systems. Health policy experts and advocates have long been demanding increased budgetary allocation for a strong and comprehensive primary health care of financial crunch. The Centre should system in the rural regions. The improvement of announce a special rural package to help the PHCs and CHCs should be done on a war footing. states tide over the current crisis. This stimulus The COVID-19 pandemic exposed India’s should focus on ensuring food and livelihood vulnerability to health shocks and demonstrated security for families. The public distribution the need for increased public investment in the system (PDS) must be strengthened to ensure health sector. India has the lowest healthcare accessibility and availability of food grains, as budget in the world at 1.26 percent of GDP; as well as the MGNREGA. compared to the goal of 2.5 percent listed in the National Health Policy.59 Near-neighbours like Through cash transfers, the government Bangladesh and Pakistan, for example, spend should provide a safety net to all households over 3 percent of their GDP on public health. who have lost their livelihoods due to India ranks 145th out of 195 countries on quality lockdowns. According to Mahesh Vyas, CEO and accessibility to healthcare60 as per the Global of Centre for Monitoring Indian Economy, Burden of Disease study, lower than China (48), over 10 million Indians have lost their jobs Sri Lanka (71) and Bangladesh (133). With since the onslaught of the second wave of COVID-19 further exposing the rural-urban COVID-19; overall 97 percent of households disparities in health, higher spending on the across the country have witnessed a decline in rural infrastructure has become even more incomes.63 Therefore, paying every household urgent, including, for instance, for hospitals in rural districts a modest monthly amount with ICU facilities. Government can adopt the to sustain themselves during the pandemic model of public-private partnerships to urgently (without withdrawing their eligibility for other, set up the necessary facilities.61 existing schemes) is likely to be more effective than trying to identify the “needy”—after all, 4. Provide a special economic package for rural no household is unaffected by the pandemic. India. Economist and Nobel laureate Amartya The normative arguments made against cash Sen has argued that restrictions on movement transfers—i.e., that they are unproductive—no such as lockdowns and social distancing, must longer hold as the lockdowns have left millions be accompanied by arrangements for income, jobless and many families have lost either and food, and medical attention which are all likely both of their breadwinners to COVID-19. to be impacted by those rules.62 The challenge is enormous, and states are facing varying degrees

24 Guy Standing, an economist from the University of Bath, has argued that a universal basic income leads to better physical and mental health, and brings about clear improvements in nutrition, 6. Fill vacant healthcare positions and recruit productivity, and the status of women.64 Other more staff. As discussed earlier in this report, economists, including Nobel laureate Abhijit many positions are lying vacant in Sub-Centres, Banerjee, have recommended greater public Primary Health Centres, and Community spending to address India’s current economic Health Centres across the country. All these problems. The massive socio-economic fallout positions should be filled in immediately. A of the second wave of the pandemic calls for good example is the state of Jharkhand, which stepping up of public spending. Fiscal tightening has started recruiting nurses on a large scale. at this juncture can prove devastating for the State governments should consider recruiting economy. temporary staff where necessary to address the surge in cases. 5. Ramp up testing and vaccination. Scanty testing in the rural districts is a matter of concern, to 7. Impose strict rules on gatherings. Gatherings gain a clearer picture of the infection rates, for weddings and religious rituals must be launch a targeted response, and arrest the curbed immediately to contain the spread further spread. More Rapid Response Teams of the virus. Police have been deployed to should be deployed in the rural regions for prevent such gatherings since last year, but for door-to-door visits where health workers check better compliance, community leaders and the body temperatures, oxygen saturation levels, panchayat should take the lead in enforcing and other symptoms. Despite the surge in restrictions. cases in rural areas, only 13 percent have been vaccinated. This indicates the urgent need to 8. Distribute essential medication and scale up the vaccine rollout.65 Testing units can equipment. There is an urgent need to be camped at local bus stops, especially where mobilise resources for the distribution of caseloads are heavy. Delhi is an example of this implements like thermometers and pulse strategy.66 oximeters to families, and followup should be conducted by the community health workers. The panchayati raj and village health and nutrition committee can be involved in this task. Home medicine kits can be provided to affected households, along with proper instructions on how to use them.

25 Still the most potent defence against COVID-19, according to experts, is the use of masks, and hand hygiene. With average monthly expenditure of rural households at INR also been crucial so far in the management 6,646 and many families heavily indebted, the of the pandemic in these districts. Therefore, purchase of masks, sanitisers, and soaps will be women should be at the heart of India’s beyond reach for many. These should be made COVID-19 response in rural areas. Women freely available in Sub-Centres, PHCs, and frontline workers should be vaccinated on an CHCs, and be distributed by ASHAs and health urgent basis, and the stipend of ASHA workers workers. Panchayats should launch dedicated must be increased. There should be special sanitation drives across their jurisdictions. The guidelines for the more vulnerable groups— Members of Parliament Local Area Development for example, pregnant women: given the Scheme (MPLADS) funded67 by Government shortage of medical facilities in rural areas and of India enables Members of Parliament (MPs) the rising COVID-19 cases, there is a danger to spend on enabling community assets such that non-Covid medical needs, including as drinking water, primary education, public births, get neglected. health, sanitation, and roads. The funds are allowed to be used for the purchase of medical 10. Encourage the private sector to invest in rural equipment for hospitals, N95 masks, PPEs, and health. Experts argue that if businesses pursue ventilators.68 MPs should be encouraged to use social progress, then poverty, pollution, and the funds under MPLADS to distribute these disease would decline and their own profits essentials in their constituencies. would increase.69 Companies that consider collective impactg will not only advance social 9. Create a gender-sensitive response. Women are progress but also find economic opportunities disproportionately impacted by the pandemic, that their competitors are missing. Pursuing a with inequalities in access to health and collective agenda will be in the private sector’s nutrition getting exacerbated and the burden of own interest, as businesses in India are also unpaid care work increasing manifold. Women, experiencing a decline in demand on account however, are the backbone of agriculture in India of the economic slowdown. and they play an essential role as caregivers. Women’s self-help groups and ASHAs have

g The concept of collective impact was developed by John Kania and Mark Kramer. Collective impact is the commitment of a group of actors from different sectors to a common agenda for solving a specific social problem, using a structured form of collaboration.

26 A rural recovery programme alongside expansion of welfare services will help businesses expand their markets. Therefore, India’s private sector should be encouraged to invest focuses on providing basic healthcare facilities in building social infrastructure in the rural and services in remote rural areas through the regions. A healthy population is, after all, the deployment of Mobile Medical Vans.72 The bedrock of economic growth. A recent report by beneficiaries have been women, children and NITI Aayog70 calls for investment opportunities the elderly, whose general health is neglected in healthcare through tax incentives. It provides due to poverty and lack of resources and for 10-percent deduction on profits for hospitals awareness. The CSR wing of Ambuja Cement is in rural areas. This is an opportunity for the engaged in awareness campaigns on protocols private sector to invest in rural healthcare for like handwashing and social distancing.73 tax incentives. Sakhi-womenh volunteers work with local health authorities to provide services. Such There are existing examples of Indian companies initiatives need to be scaled up in an urgent providing healthcare in the rural areas through manner. As do philanthropic efforts. Venture CSR (Corporate Social Responsibility) initiatives. capitalist, Vinod Khosla, has set an example For instance, Tata Steel Limited launched by donating $10 million to the country’s its initiative, ‘MANSI’ (Maternal & Newborn Covid fight.74 Texas-based philanthropists, Raj Survival Initiative) which reduces mortality and Aradhana Asava, have also offered up to among neonates and infants by enhancing the $25,000 in donations to support pandemic capacity of government health volunteers in the relief in their native India.75 Home-Based Newborn Care (HBNC) system.71 The project is being implemented in 12 blocks across the states of Jharkhand and Odisha. Meanwhile, an initiative by Hindustan Petroleum

h Sakhis – a group of women volunteers trained by Ambuja Cement Foundation in healthcare services

27 Conclusion

s the pandemic’s second wave makes further inroads into India’s hinterland, the country could be looking at the possibility of a disaster This special report outlined a ten-point similar to what occurred in the urban agenda for immediate action in India’s rural regionsA early this year. And because 65.53 percent of districts. Beyond this urgent course of action, the country’s entire population are rural, targeted, however, it is equally important that India turns comprehensive strategies must be undertaken to the crisis into an opportunity to rethink current prevent such a catastrophe from happening. The approaches to development: rather than being situation is already dire, and requires immediate urban-centric, India must develop better health attention: medical infrastructures are weak, there and welfare systems in the rural regions and are severe shortages in qualified medical staff, the make the countryside more resilient to shocks vaccine rollout is slow, and there is poor adherence like COVID-19. The blueprint presented in this to safety protocols. These, coupled with enduring, report can go a long way in not only addressing large-scale poverty and lack of livelihoods—which the current health crisis in India’s villages, but also have existed long before COVID-19. in the achievement of cross-cutting sustainable development goals: SDG 1 (no poverty); 2 (zero hunger); 3 (good health and well-being); 5 (gender equality); 8 (decent work and economic growth); and 10 (reduced inequalities).

28 Endnotes

1 HT Correspondent. ‘As India records 126,260 new Covid-19 cases, curbs in more states’, Hindustan Times, April 8, 2021, https://www.hindustantimes.com/india-news/as-india-records-126k-new-cases-curbs-in-more-states-101617821009127.html 2 “SBI report emphasises on vaccination, says nearly half of the new cases in rural India”, The Hindu, May 7, 2021, https:// www.thehindu.com/news/national/sbi-report-emphasises-on-vaccination-says-nearly-half-of-the-new-cases-in-rural-india/ article34506912.ece 3 Aditya Bidwai, “After affecting big cities, Covid-19 is now hitting India’s rural areas hard”, India Today, May 7, 2021, https:// www.indiatoday.in/coronavirus-outbreak/story/covid-19-hitting-india-rural-areas-hard-1799715-2021-05-07 4 Vishakha Chaman, “In Haryana, most rural Covid deaths in Hisar”, The Times of India, May 18, 2021, https://timesofindia. indiatimes.com/city/gurgaon/in-haryana-most-rural-covid-deaths-in-hisar/articleshow/82723062.cms 5 Gopi Maniar Ghangar, “Second wave hits Gujarat’s rural pockets; village loses 90 people to Covid”, India Today, May 5, 2021, https://www.indiatoday.in/india/gujarat/story/second-wave-hits-gujarats-rural-pockets-village-loses-90-people-to- covid-1798928-2021-05-05 6 Mithilesh Dar Dubey, ‘Testing times for rural India as delay in RT-PCR test results may hasten the Covid spread’. GoanConnection, May 5, 2021. https://en.gaonconnection.com/testing-times-for-rural-india-as-delay-in-rt-pcr-test-results- may-hasten-spread-of-covid19-in-villages/ 7 “In rural India, fear of testing and vaccines hampers COVID-19 fight”, Livemint, June 5, 2021, https://www.livemint.com/ news/india/in-rural-india-fear-of-testing-and-vaccines-hampers-covid-19-fight-11622860807008.html 8 Atul Thakur, “Proof that COVID is now a rural pandemic in India”, Times of India, May 12, 2021, https://timesofindia. indiatimes.com/india/proof-that-covid-is-now-a-rural-pandemic-in-india/articleshow/82569846.cms 9 Vignesh R, ‘Vaccination in rural India trails urban areas as cases surge’. The Hindu, May 18, 2021, https://www.thehindu. com/news/national/vaccination-in-rural-india-trails-urban-areas-even-as-cases-surge/article34589734.ece 10 Vignesh R, ‘Vaccination in rural India trails urban areas as cases surge’ 11 Bhavya & Himanshi, ‘Low smartphone reach coupled with lack of digital literacy hit rural India Covid vaccine drive’. The Economic Times, May 16, 2021, https://economictimes.indiatimes.com/news/india/net-hesitancy-hiccups-for-rural-india-vax- drive/articleshow/82671780.cms?utm_source=contentofinterest&utm_medium=text&utm_campaign=cppst 12 Pranab M, Harpreet B and Sudhir S, “Covid vaccine a distant reality in rural India, shows app”, The New Indian Express, May 23, 2021, https://www.newindianexpress.com/nation/2021/may/24/covid-vaccine-a-distant-reality-in-rural-india-shows- app-2306615.html

29 13 Mithilesh Dar Dubey, “44% rural citizens willing to pay for corona vaccine; two-third want its price to not exceed Rs 500: Gaon Connection Survey”. GaonConnection, December 23, 2020, https://en.gaonconnection.com/44-rural-citizens-willing-to- pay-for-the-corona-vaccine-two-third-want-its-price-to-not-exceed-rs-500-gaon-connection-survey/ 14 Trading Economics, “India – Rural Population”, https://tradingeconomics.com/india/rural-population-percent-of-total- population-wb-data.html#:~:text=Rural%20population%20(%25%20of%20total,compiled%20from%20officially%20 recognized%20sources. 15 “76% of rural Indians can’t afford a nutritious diet: study”, The Hindu, October 17, 2020, https://www.thehindu.com/news/ national/76-of-rural-indians-cant-afford-a-nutritious-diet-study/article32881678.ece 16 Debmalya Nandy, “COVID and rural economic distress: Food for all and work for all should be the way forward”, GaonConnection, June 2, 2021, https://en.gaonconnection.com/covid-second-wave-rural-economic-distress-food-hunger- lockdown-mgnrega-unemployment-pds-migrant-workers/ 17 Sneha Mordani, “Centre gives states blueprint for containment of COVID-19 in rural areas”, India Today, May 17, 2021, https:// www.indiatoday.in/coronavirus-outbreak/story/centre-states-blueprint-containment-covid-rural-areas-1803300-2021-05-17 18 Government of India, Ministry of Health & Family Welfare, SOP on COVID-19 Containment & Management in Peri-urban, Rural & Tribal areas, May 16, 2021, https://www.mohfw.gov.in/pdf/ SOPonCOVID19Containment&ManagementinPeriurbanRural&tribalareas.pdf 19 “Govt issues SOPs to combat Covid in rural areas, focus on awareness, screening, isolation”, India Today, May 16, 2021, https://www.indiatoday.in/coronavirus-outbreak/story/government-sop-covid-rural-india-1803175-2021-05-16 20 G S Mudur, “Union Health ministry releases guidelines for Covid management in rural areas”, The Telegraph Online, May 17, 2021, https://www.telegraphindia.com/india/coronavirus-outbreak-union-health-ministry-releases-guidelines-for-covid- 19-management-in-rural-areas/cid/1815812 21 Rina Chandran, “Drones are delivering vaccines to rural communities in India”, World Economic Forum, May 25, 2021. https:// www.weforum.org/agenda/2021/05/india-is-now-testing-drones-to-deliver-covid-19-vaccines/ 22 Government of India, Ministry of Health and Family Welfare Statistics Division, Rural Health Statistics 2019-20, (New Delhi: Ministry of Health and Family Welfare Statistics Division, 2020), https://hmis.nhp.gov.in/downloadfile?filepath=publications/ Rural-Health-Statistics/RHS%202019-20.pdf 23 Government of India, Ministry of Health and Family Welfare Statistics Division, Rural Health Statistics 2019-20 24 Government of India, Ministry of Health and Family Welfare Statistics Division, Rural Health Statistics 2019-20 25 Government of India, Ministry of Health and Family Welfare Statistics Division, Rural Health Statistics 2019-20 26 Government of India, Ministry of Health and Family Welfare Statistics Division, Rural Health Statistics 2019-20 27 Piyush Srivastava, “Covid: RAT kits sent from UP headquarters turns out to be faulty, The Telegraph Online, May 15, 2021, https://www.telegraphindia.com/india/coronavirus-outbreak-rat-kits-sent-from-the-uttar-pradesh-headquarters-turns-out- to-be-faulty/cid/1815614

30 28 “Bihar struggles to cope with rising COVID-19 cases”, The Hindu, April 16, 2021, https://www.thehindu.com/news/national/ other-states/bihar-struggles-to-cope-with-rising-covid-19-cases/article34331090.ece 29 Agrima Raina, “ASHA workers are hailed as Covid warriors but only 62% have gloves, 25% have no masks”, The Print, September 21, 2020, https://theprint.in/opinion/asha-workers-are-hailed-as-covid-warriors-but-only-62-have-gloves-25- have-no-masks/506623/ 30 Government of India, Ministry of Health and Family Welfare Statistics Division, Rural Health Statistics 2019-20 31 Government of India, Ministry of Health and Family Welfare Statistics Division, Rural Health Statistics 2019-20 32 Government of India, Ministry of Health and Family Welfare Statistics Division, Rural Health Statistics 2019-20 33 Oommen C Kurian, “Does budget 2020 provide material support for the ongoing health reforms?”, Observer Research Foundation, February 7, 2020, https://www.orfonline.org/expert-speak/does-budget-2020-provide-material-support-for- the-ongoing-health-reforms-61169/ 34 Oommen C Kurian, “Does budget 2020 provide material support for the ongoing health reforms?” 35 Oommen C Kurian, “The war budget: Can the Centre fight a pandemic simply by turning water into wellbeing?”, Observer Research Foundation, February 1, 2021, https://www.orfonline.org/expert-speak/war-budget-can-centre-fight-pandemic- simply-turning-water-wellbeing/ 36 World Bank, https://data.worldbank.org/indicator/SH.XPD.GHED.GD.ZS?contextual=default&locations=IN-BR-ZA-RU- CN 37 World Bank, https://data.worldbank.org/indicator/SH.XPD.GHED.GD.ZS?contextual=default&locations=IN-BR-ZA-RU- CN 38 Uma Vishnu, “Prabhat Jha: ‘Lack of death data prolongs pandemic… survey villages’”, India Express, May 25, 2021, https:// indianexpress.com/article/india/prabhat-jha-lack-of-death-data-prolongs-pandemic-survey-villages-7328846/ 39 Uma Vishnu, “Prabhat Jha: ‘Lack of death data prolongs pandemic… survey villages’” 40 Asit Ranjan Mishra, “Growth setback likely as rural India begins to reel from COVID-19”, Livemint, May 5, 2021, https:// www.livemint.com/economy/growth-setback-likely-as-bharat-faces-2nd-wave-11620153341837.html 41 Shoba Suri, “Coronavirus pandemic and cyclone will leave many Indians hungry and undernourished”, Observer Research Foundation, July 16, 2020, https://www.orfonline.org/research/coronavirus-pandemic-and-cyclone-will-leave-many-indians- hungry-and-undernourished/ 42 Meenakshi Ray, “Free ration to 800 million people till Diwali, announces PM Modi”, Hindustan Times, June 7, 2021, https:// www.hindustantimes.com/india-news/free-ration-to-800-million-people-till-diwali-announces-pm-modi-101623071436210. html

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About the Authors

Malancha Chakrabarty is Fellow, and Shoba Suri is Senior Fellow at ORF.

Cover image: Getty Images / Hindustan Times Back cover image: Getty Images/Andriy Onufriyenko

34 Ideas . Forums . Leadership . Impact

20, Rouse Avenue Institutional Area, New Delhi - 110 002, INDIA Ph. : +91-11-35332000. Fax : +91-11-35332005 E-mail: [email protected] Website: www.orfonline.org